Neonatal mortality rates are declining in all regions, but more slowly in sub-Saharan Africa

The first 28 days of life – the neonatal period – is the most vulnerable time for a child’s survival. The good news is that neonatal mortality is declining globally. The worldwide neonatal mortality rate fell by 40 per cent between 1990 and 2013 - from 33 to 20 deaths per 1,000 live births. Over the same period, the number of newborn babies who died within the first 28 days of life declined from 4.7 million to 2.8 million.

Neonatal mortality rates are declining in all regions, but more slowly in Sub-Saharan Africa

Neonatal mortality rate by region, 1990 and 2013

Source: UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

Neonatal mortality rates are declining in all regions, but more slowly in Sub-Saharan Africa

Neonatal mortality rate by region, 1990 and 2013

Source: UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

This positive trend occurred in every region – all regions reduced the neonatal mortality rate by 27 per cent or more. East Asia and the Pacific achieved the most impressive improvement in newborn survival with a reduction of 60 per cent in the neonatal mortality rate.

Because mortality in the neonatal period (the first 28 days of life) tends to decline more slowly than the post-neonatal period (1-59 months), every region of the world is experiencing an increase in the proportion of newborn deaths. As a result, neonatal deaths as a proportion of under-five deaths increased globally from 37 per cent in 1990 to 44 per cent in 2013. In four regions – South Asia, East Asia and the Pacific, Latin America and the Caribbean, and the Middle East and North Africa half or more of all under-five deaths are now concentrated in the first month of life.

Declines in neonatal mortality are not keeping pace with declines in post-neonatal mortality

Source: UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

Declines in neonatal mortality are not keeping pace with declines in post-neonatal mortality

Source: UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

The gaps in progress in newborn survival are particularly stark when comparing the progress of individual countries. Across West and Central Africa, for example, the risk of a baby dying within the first 28 days of life is almost 10 times higher than the risk facing a baby born in a high-income country. With 47 neonatal deaths per 1,000 live births, Angola is the riskiest place to be a newborn, while Iceland and Luxembourg have only 1 neonatal death per 1,000 live births. Almost two-thirds of neonatal deaths occur in just 10 countries, with India accounting for more than a quarter and Nigeria for about a tenth.

Approximately two thirds of all neonatal deaths worldwide occur in 10 countries

Neonatal mortality rates by country and countries with the highest numbers of neonatal deaths, 2013

Map disclaimer: Maps on this site do not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers.

Source: UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

Approximately two thirds of all neonatal deaths worldwide occur in 10 countries

Neonatal mortality rates by country and countries with the highest numbers of neonatal deaths, 2013

Map disclaimer: Maps on this site do not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers.

Source: UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

In 2013, almost 1 million newborns died on the day they were born, accounting for 16 per cent of all under-five deaths and more than a third of all neonatal deaths. A total of 2 million newborns died within the first seven days after birth, representing 73 per cent of all neonatal deaths. Between 1990 and 2013, 86 million newborn babies born worldwide died within their first 28 days of life.

Globally, the main causes of neonatal deaths are preterm birth complications (35 per cent), intrapartum-related complications (complications during labour and delivery) (24 per cent), and sepsis (15 per cent). Together, these three causes account for almost three quarters of all neonatal deaths.

Preterm birth complications cause more than a third of neonatal deaths while complications related to labour and delivery contribute to one quarter

The causes of neonatal deaths vary by region. In sub-Saharan Africa and South Asia, for example, the main infectious diseases, including sepsis, pneumonia, diarrhoea and tetanus, account for approximately a quarter of all neonatal deaths. In high-income countries, by contrast, infectious diseases account for only 7 per cent of neonatal deaths. To accelerate the progress in newborn survival, global efforts must be intensified to reduce these infectious diseases specifically in sub-Saharan Africa and South Asia.

Preventable infectious diseases are still a major cause of neonatal deaths in sub-Saharan Africa and South Asia

A newborn’s chances of survival are particularly dependant on income, maternal education and place of birth. Lower household wealth, an uneducated mother and birth in a rural area lower a newborn’s chances of survival within the first 28 days of life. Children born in urban areas, to the richest households and to mothers with secondary or higher education face a far greater risk of dying compared to children born into high-income and upper-middle-income countries.

The critical determinants of newborn mortality underscore the need for a comprehensive response to the growing proportion of neonatal deaths worldwide. While quality health care is undoubtedly important to both the mother and newborn, so too are preventative efforts to keep girls in school, stop child marriage, reduce adolescent fertility and promote the overall health, nutrition and education of adolescent girls. Protecting the basic rights of all girls and women is one of the surest ways to increase prospects for a safe pregnancy and a healthy newborn.

Children born to poorer households, to mothers with no education and living in rural areas face a higher risk of dying in the first 28 days of life

Source: UNICEF analysis based on MICS and DHS surveys, as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

Note: Data are based on MICS or DHS surveys that took place since 2005. Data from the most recent survey are used for countries with multiple surveys. Data by wealth quintile are based on 57 surveys, data by education level order on 64 surveys and data by residence on 65 surveys.

Children born to poorer households, to mothers with no education and living in rural areas face a higher risk of dying in the first 28 days of life

Source: UNICEF analysis based on MICS and DHS surveys, as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2014, UNICEF, New York 2014.

Note: Data are based on MICS or DHS surveys that took place since 2005. Data from the most recent survey are used for countries with multiple surveys. Data by wealth quintile are based on 57 surveys, data by education level order on 64 surveys and data by residence on 65 surveys.

This report looks at causes of death and coverage of key interventions for mother and newborn and highlights initiatives by governments, civil society and the private sector to accelerate progress on child survival.

Recent estimates show that the number of under-five deaths worldwide has declined by half since 1990, from 12.7 million to 6.3 million today. Yet, 17,000 children under age five still die every day in 2013.

DEFINITION OF INDICATORS

Under-five mortality rate: Probability of dying between birth and exactly 5 years of age, expressed per 1,000 live births.Infant mortality rate: Probability of dying between birth and exactly 1 year of age, expressed per 1,000 live births.

Neonatal mortality rate: Probability of dying during the first month of life, expressed per 1,000 live births.

DATA SOURCES AND METHODOLOGY

If each country had a single source of high-quality data covering the last few decades, reporting on child mortality levels and trends would be straightforward. But few countries do, and the limited availability of high-quality data over time for many countries makes generating accurate estimates of child mortality a considerable challenge.

Nationally representative estimates of child mortality can be derived from several sources, including civil registration, censuses and sample surveys. Demographic surveillance sites and hospital data are excluded because they are rarely representative. The preferred source of data is a civil registration system that records births and deaths on a continuous basis, collects information as events occur and covers the entire population. If registration coverage is complete and the systems function efficiently, the resulting child mortality estimates will be accurate and timely. However, many countries remain without viable or fully functioning vital registration systems that accurately record all births and deaths—only around 60 countries have such systems. Therefore, household surveys, such as the UNICEF-supported Multiple Indicator Cluster Surveys and the US Agency for International Development–supported Demographic and Health Surveys, which ask women about the survival of their children, are the basis of child mortality estimates for most developing countries.

The United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) seeks to compile all available national-level data on child mortality, including data from vital registration systems, population censuses, household surveys and sample registration systems. To estimate the under-five mortality trend series for each country, a statistical model is fitted to data points that meet quality standards established by IGME and then used to predict a trend line that is extrapolated to a common reference year, set at 2013 for the estimates presented here. Infant mortality rates are generated by either applying a statistical model or transforming under-five mortality rates based on model life tables. Neonatal mortality rates are produced using a statistical model that uses under-five mortality rates as input. These methods provide a transparent and objective way of fitting a smoothed trend to a set of observations and of extrapolating the trend from 1960 to the present.

A peer-reviewed collection of articles that makes a vital contribution to transparency on UN IGME's methodology for child mortality estimation.

Topics include: an overview of the child mortality estimation methodology developed by UN IGME, methods used to adjust for bias due to AIDS, estimation of sex differences in child mortality, and more. The collection was produced with support from UNICEF and the independent technical advisory group of IGME. Read more.

CHANGE IN ESTIMATION PROCESS

The UN IGME continually seeks to improve its methods. Since 2013, estimates and projections of under-five mortality have been produced using the Bayesian B-splines bias-adjusted model, referred to as the B3 model. Compared with the previously applied Loess estimation approach the B3 model better accounts for data errors, including biases and sampling and nonsampling errors in the data. It can better capture short-term fluctuations in the under-five mortality rate and its annual rate of reduction and thus is better able to account for evidence of acceleration in the decline of under-five mortality from new surveys. Validation exercises show that the B3 model also performs better in short-term projections.

Estimates of infant mortality rates are generated by applying the B3 model for countries with high-quality vital registration data. For other countries, infant mortality rates are derived from under-five mortality rates using model life tables that contain known regularities in age patterns of child mortality. This approach ensures that the internal relationships of the two indicators are consistent with established norms. Estimates of neonatal mortality rates are produced using a statistical model that uses under-five mortality rates as an input. These methods provide a transparent and objective way of fitting a smoothed trend to a set of observations and of extrapolating the trend to the present.

In 2012 the UN IGME produced sex-specific estimates of the under-five mortality rate for the first time. In many countries fewer sources provide data disaggregated by sex than for both sexes combined. So the UN IGME uses the available data by sex to estimate a time trend in the sex ratio (male–female) of child mortality rather than estimating child mortality trends by sex directly from reported mortality levels by sex. Since 2013 a Bayesian model developed by the UN IGME has been used to estimate sex ratios of child mortality, with a focus on identifying countries with outlying levels or trends.

The full details of the methodology used in the estimation of infant and under-five mortality rates for 2006 are available in the following working paper: UNICEF, WHO, The World Bank and UN Population Division, Levels and Trends of Child Mortality in 2006: Estimates developed by the Inter-agency Group for Child Mortality Estimation’, New York, 2007. Working Paper [PDF]